Sun protection behaviors among children aged 6−18 years old, the role of socioeconomic factors: A cross‐sectional study

Abstract Background and Aims Evaluation of sun protection behavior and related factors in children aged between 6 and 18 years in Isfahan, Iran. Methods This cross‐sectional study was conducted at outpatient pediatric clinics affiliated with Isfahan University of Medical Sciences, Isfahan, Iran during the summer of 2021. A checklist was designed, and the interviewer used that to gather the required information including children's demographic characteristics, families' socioeconomic data, and sun‐protective behaviors in children. Results The mean ± standard deviation (SD) age of children was 10.54 ± 3.61. Among the study population, 63.7% of children were male. The most common skin phototypes were II and III (33.5% each). 83.8% of children used at least one method of sun protection (94.5% of girls, 77.6% of boys, p < 0.001). Wearing long‐sleeved clothes was the most frequent UV‐protection method (48%), while sunscreen application was the least prevalent method (28.1%). Sun protection behaviors were more frequent among urban children (86.7%, p = 0.009) and children with wealthy families (94%, p = 0.035). Sun protection methods were used by most of the children whose mothers applied sunscreen on a daily basis (90.2%, p = 0.002) and all of the children whose mothers held a master's degree or above (100%, p = 0.004). Conclusion Children's sun protection behavior is directly associated with demographic characteristics, families' socioeconomic level and maternal usage of sun protection measures. It is necessary to provide information and education about sun protection methods and the risks of excessive sun exposure to families and children, as well as facilitate their access to these.


| INTRODUCTION
Solar ultraviolet (UV) radiation is considered to be the primary cause of skin cancers. 1 As a result of constant exposure to sunlight and solar UV radiation deoxyribonucleic acid (DNA) damage can occur, leading to photoaging and cancer. 2,3This results from the interaction between UV light and a subset of molecules called chromophores.The absorption of UV light by chromophores in the epidermis results in adverse biological effects including oxidative damage, activating transcription factors, DNA mutations, and damage to cell membranes. 4cently there is an increasing trend in skin cancer incidence worldwide. 5In the United States, skin cancer affects one in five people. 6In Iran, skin cancer accounts for 32.7% of all cancers diagnosed. 7Skin cancer mortality, in Iran, has grown around tenfold between 1995 and 2004 (from 0.06 to 0.7 in 100,000 people), despite being preventable. 8There are some known risk factors for skin cancers which could be divided into endogenous and exogenous factors. 9Endogenous factors include skin phototype, presence and number of melanocytic nevi, and familial history of skin cancer. 9Cumulative sun exposure duration, UV protection behaviors, and history of sunburn are among exogenous factors. 10Excessive UV radiation is reported to be the most significant risk factor for skin cancer, accounting for over 90% of nonmalignant skin cancer and 65% of malignant melanoma globally. 11,12 has been shown that 25−50% of the total UV exposure up to the age of 60 is accumulated during childhood, and children have up to three times higher annual sun exposure compared to adults. 13Given that children's skin, especially that of those under the age of three, has less melanin and a thinner stratum corneum and therefore making it more sensitive to UV radiation, 14,15 it can be deduced that early exposure to sunlight significantly affects the incidence of skin cancer in the future. 12us, both primary (photoprotection) and secondary prevention should be applied at an early stage of life. 16,17Based on the protocol published by World Health Organization (WHO), photoprotection is achieved by avoiding the sun, staying in shade, wearing clothes that block the sunlight, hats, and sunglasses, and using sunscreens. 18,19spite the high incidence of skin cancer in Iran, 20 there are limited studies regarding sun protection behaviors in the Iranian population, especially among children.In addition, due to the importance of sunburn prevention and sunlight protection in childhood, as significant factors in reducing the risk of skin cancer, 21 studies regarding the usage frequency of sun protection methods and the variables affecting sun protection behaviors are crucial.In the current study, we investigate the frequency of sun protection behaviors among children and their mothers in Isfahan, a city located in the center of Iran.We also evaluate the association between demographic/socioeconomic variables and sun protection behaviors in children.

| Study setting and selection criteria
This cross-sectional descriptive study was conducted at outpatient pediatric clinics in two different regions of the city (Imam Hossein Children's Hospital and Al-Zahra Hospital), affiliated with Isfahan University of Medical Sciences, Isfahan, Iran during the summer of 2021.To calculate the sample size while considering a 95% confidence level (z = 1.96 α ), sun-protective behavior relative frequency of 68.8% (p = 0.688), according to the study by Nahar et al. 22 and a margin of error of 0.06 (d = 0.06), a sample size (n) of 230 individuals was calculated using ( ) formula.
The Data were gathered from two geographically distinct hospitals to reduce the potential biases.

| Statistical analysis
Variables that were continuous were expressed as means with standard deviations (SD), while categorical variables were expressed as numbers (percentages).We compared the means of the continuous variables between two or more groups, using the independent Student t-test (or analysis of variance test) and the Mann−Whitney test (or Kruskal−Wallis test) for the variables with normal and nonnormal distributions, respectively.We assess the difference in the distribution of the categorical variables between groups of demographic variables using the χ 2 test.We used SPSS 20.0 for Windows to conduct statistical analyses.The statistical significance of this study was determined by the two tailed p Values less than 0.05.

| RESULTS
Among a total of 373 enrolled children, 21 of them had incomplete data and were excluded from the study.The mean ± SD age of children and their mothers were 10.54 ± 3.61 and 36.6 ± 5.9 respectively.63.7% of children were male.Children's/mothers' characteristics are summarized in Table 1 (Table 1).The most common skin phototypes were II and III (33.5% each).17.62% had non-dermatological underlying diseases while only 0.85% reported dermatological conditions.69.2% of the families were living in urban areas.
83.8% of children used at least one method of sun protection.94.5% of girls and 77.6% of boys used sun protection methods (p < 0.001).
Urban children used sun protection methods more than children living in rural areas (86.7% compared to 74.5%, p = 0.009).For families with income over 100 M IRR, 94% of their children used sun protection methods, compared to 85.6% among families with 50−100 M IRR income, and 80% among those earning less than 50 M IRR (p = 0.035).
The frequency of sun protection behaviors among children whose mothers used sunscreen was 90.2% (p = 0.002).The percentage of using sun protection methods in children whose mothers held master's degrees and above was 100% (p = 0.004).There are no significant correlations between the frequency distribution of children's skin phototypes, the mean age of children/mothers, and sun protection behaviors (p > 0.05).
Sunburn history was more frequently reported for skin phototypes of I (56.2%) and II (61.1%) as compared to other phototypes (p = 0.001).
Table 2 shows the prevalence of the photoprotection methods among children (separately for each method) and correlations between the demographic/socioeconomic characteristics and the various sun protection methods (Table 2).Wearing long-sleeved clothes (48%) was the most frequent UV-protection method, while the application of sunscreen was the least used method (28.1%).other children, children of employed mothers used sunglasses (50%, p = 0.001), sunscreens (43.6%, p = 0.001), and visors (41%, p = 0.02) more frequently.
Table 3 presents the relationship between demographic characteristics and frequency distributions of sunburn history, daily sunscreen renewal, the mean daily sun exposure in the previous month for children, and mothers' sunscreen use (Table 3).Mean daily sun exposure in the last month for boys (p < 0.001) and urban children (p = 0.002) was significantly higher than for girls and rural children, respectively.Mothers with higher educational levels (more than 67%, p < 0.001) and employed mothers (78.2%, p < 0.001) had more frequent sunscreen daily use.

| DISCUSSION
The result of our study demonstrated that about 80% of children used at least one method of sun protection, while applying sunscreen was the least frequent method.We found that the most frequent sun protection behaviors were wearing long-sleeve clothes and wide-brimmed hat.Sun protection behaviors and sunburn history were strongly correlated with demographic, phenotypic, and socioeconomic characteristics in children.There are some differences in sun protection behaviors between the two genders.Among girls, the prevalence of wearing long-sleeved clothes, sunglasses, and visors was higher while wearing wide-brimmed hats was more common among boys.Children whose mothers were employed, had higher education, came from wealthy families, and lived in urban areas were more likely to use sunscreen and other sun-protective methods, such as sunglasses, visors, and wide-brimmed hats.
In our study population, the most common sun-protective method among children was wearing long-sleeve clothes.This result is in agreement with the previous studies in Iran. 24,25Our study found that sunscreen was the least commonly used method.In a similar study in southwest Iran, among 385 high-school students, wearing long-sleeve clothes was the most common sun protection method, and applying sunscreen was the second most prevalent. 24e discrepancy in the prevalence of sunscreen use could be due to the difference between the mean age of the participants in our study (about 10 years) and those in the previous study (about 14 years).It is possible that younger children are less inclined to use sunscreen.
Nevertheless, the findings reported by Patel et al. contradict this notion, as they found that the prevalence of sunscreen use was higher among younger children. 26This suggests that sun protection behavior is influenced by multiple factors.Also, it is expected that the use of each sun protection method varies across different regions.
Comparing two studies conducted in the United States, wearing longsleeve clothes was the most prevalent sun protection method in Minnesota (about 70%), while it was the least common method in Florida (less than 10%). 27,28 a telephone survey in Australia, among 1140 parents/ guardians of children aged under 11 years old, the two most commonly used methods were wearing hats and sunscreen. 29The differences in the prevalence of sun protection methods between our study and the one in Australia could be related to the higher public awareness regarding sun protection methods compared to Iran.
Public educational programs regarding skin cancer prevention have been implemented in Australia for decades. 29 our study, there are some significant differences in sun protection behaviors as well as a difference in mean daily sun exposure between boys and girls.In agreement with our study, similar results were reported in the study conducted among 860 children in three regions of the United States. 26Possible explanations for this could be the differences in cultural and mental norms as well as the differences in gender-specific clothing.Moreover, the Hijab in Iran might be also a reason for the higher prevalence of wearing longsleeve clothes among females.Furthermore, girls tend to care more about cosmetics and beauty; which can result in more frequent utilization of sunscreen.In line with our findings, in a previous study in Iran among 10,555 high-school students, the scores of knowledge, attitude, and behavior in sun protection were higher among females. 25sults of our study demonstrated, there is a significant correlation between mothers' sunscreen use and their children's sun protection behaviors.This can be due to children viewing their mothers as role models when it comes to sun protection. 30,31A B L E 3 Prevalence of sunburn history, children and mothers' sunscreen use, and sun exposure during the month before the interview.Furthermore, children whose mothers held higher educational degrees or were employed exhibited more frequent sun-protective behaviors.Similar findings were achieved in previous studies by other research groups. 27,32It is possible that higher educational levels are associated with health awareness among mothers.According to a previous study, students whose parents held university degrees exhibited higher knowledge and practice scores regarding sunprotective measures. 33The use of sunglasses and sunscreen was more prevalent in higher socioeconomic families.In our study, even though urban children more frequently practiced sun-protective measures, their mean daily sun exposure was higher than that of rural children.This could be related to the attitudes of their parents towards the beneficial effects of sun exposure such as vitamin D production.In a study by Balato et al., the most common reason that mothers gave for exposing their children to sunlight was that they believed it was beneficial for children's growth. 39ong the limitations of the present study, the following can be

| CONCLUSION
The result of our study demonstrated strong correlations between the use of sun protection methods among children and various factors such as demographic characteristics, families' socioeconomic level, and parents' sun protection behaviors.Thus, it seems that ongoing education in children and families regarding the usage of sun protection methods, as well as utilizing strategies to provide easy access to these methods regardless of their socioeconomic status can contribute to more use of sun protection methods.To better understand the factors that affect sun protection behaviors among children, further studies on this topic are needed.
mentioned.The Covid-19 pandemic and the resulting quarantine conditions might have led to spending more time at home and limiting recreational activities.In consequence, it may have reduced the need for sun protection among children and families, causing an underestimation of sun protection behaviors.Although due to nationwide vaccination, the restrictions on outdoor activities were relatively reduced.Furthermore, the collected information about the frequency of each sun protection behavior and sunscreen SPF used by children were insufficient and therefore these variables were excluded from statistical analysis.Despite the aforementioned limitations, our study provides valuable information about the prevalence of sun protection behaviors and the factors influencing them, as there is a limited number of studies regarding sun protection behaviors among Iranian children.Additionally, our findings provide practical information for developing more accurate interventions and training programs aimed at improving sun protection behaviors.
The demographic, phenotypic, and socioeconomic characteristics of the study population.